Health Care Claims Examiner I (#1461)

Under general supervision, to review, evaluate, edit and process claims for payment for Behavioral Health Care Services Providers; to verify eligibility for a variety of insurance plans/programs, determine the primary payor and establish payment authorization based on program requirements; and to perform other related duties as assigned.

Distinguishing Features:

These positions are located in the Behavioral Health Care Services, Claims Processing Center and report to the Health Care Claims Manager. Health Care Claims Examiners process a variety of provider claims for services rendered to beneficiaries of Alameda County Medi-Cal program, CalWORKS program, Child and Family Services program, Healthy Families program and Indigent Children program, and other benefit plans for Psychological services.

Health Care Claims Examiner I is the entry-level class in this flexibly staffed series. This class is the training level, and incumbents are expected to gain experience and demonstrate proficiency which qualifies them to promote to the higher level after six months of full-time experience. Appointment at this level will not be extended beyond six months.

EXAMPLES OF DUTIES

NOTE: The following are illustrative examples of duties performed by the classification. However, employees may perform other related duties at an equivalent level. Not all duties are necessarily performed by each individual in this classification.

1. Reviews and processes complex claims requiring in-depth knowledge of appropriate insurance benefit plans, program regulations, payment or denial practices, policies and procedures and contract interpretation. 2. Verifies program eligibility for a variety of subcontracted plans; assesses a multitude of insurance plan benefits to determine the primary payor. 3. Reviews and analyzes claims received for compliance with Federal, State and local regulations as they relate to health care fiscal reimbursement, approved diagnosis, contracted procedure codes, completion and timeliness. 4. Researches claims status, and interprets program policies, contract obligations and insurance benefit plan policies; explains related information to providers; and assists providers in resolving problems with specific claims. 5. Determines and verifies clinical authorization status based on Plan policies; and processes claims via the managed care software system to adjudicate claims for payment. 6. Interprets supporting documentation regarding the claim as it relates to adjudication for payment; identifies the problem area and logs denied/returned claim on the client’s account record; and prepares denial and returned claim letters to the providers. 7. Analyzes provider claim practices to identify areas of concern and/or non-compliance, documents findings and notifies the Health Care Claims Manager when necessary. 8. Collaborates with other Health Care Claims Examiners to ensure shared client accounts are consistently and appropriately processed. 9. Maintains a file of pending claims awaiting payment authorization or necessary information in order to complete adjudication; periodically re-reviews for adjudication; and maintains related client records in the managed care software system. 10. Maintains the claims batch tracking database which involves the receipt, assignment and completion of all claims.

MINIMUM QUALIFICATIONS

Health Care Claims Examiner I

Either I Experience:

The equivalent of six months full-time experience in a class equivalent to or higher than Specialist Clerk I performing independent interpretation, problem-solving, research and complex clerical duties in the Alameda County classified service. (Non-classified includes District Attorney’s Office, Hospital Authority, and the Consolidated Courts.

Or II

The equivalent of one year of full-time experience in reviewing, evaluating, editing and processing claims for payment, and determining eligibility for a variety of insurance plans/programs.

NOTE: The Civil Service Commission may modify the Minimum Qualifications in the announcement of the examination.

KNOWLEDGE AND SKILLS

NOTE: The level and scope of the following knowledge and abilities are related to duties listed under the "Examples of Duties" section of this specification.

Knowledge of:

• Parameters of the provider’s contract obligations. • Current policies and requirements for an array of administered insurance plans (e.g. Medi-Cal, Healthy Families, and Children’s Indigent Plan) and other regulations as they relate to insurance benefit plan/program eligibility. • Basic policies and operations of health care insurance plans. • Federal, State and local rules and regulations as they relate to claims processing. • Modern office practices and procedures. • Business mathematical computation. • Computer application related to the work.

Alameda County offers a comprehensive and competitive benefits package that affords wide-ranging health care options to meet the different needs of a diverse workforce and their families. We also sponsor many different employee discount, fitness and health screening programs focused on overall well being. These benefits include but are not limited to*: